Summary of 2012 ASCO guideline recommendations for surveillance after breast cancer treatment

Mode of surveillance	Recommendation*
Recommended
History/physical examination	All women should have a careful history and physical examination every three to six months for the first three years after primary therapy, then every 6 to 12 months for the next two years, and then annually. The history and physical examination should be performed by a physician^¶ experienced in the surveillance of patients with cancer and in breast examination.
Patient education regarding symptoms of recurrence	Physicians should counsel patients about the symptoms of recurrence including new lumps, bone pain, chest pain, dyspnea, abdominal pain, or persistent headaches. Helpful web sites for patient education include www.cancer.net and www.cancer.org.^Δ
Referral for genetic counseling	Women at high risk for familial breast cancer syndromes should be referred for genetic counseling in accordance with clinical guidelines recommended by the US Preventive Services Task Force. Criteria to recommend referral include the following: Ashkenazi Jewish heritage; history of ovarian cancer at any age in the patient or any first- or second-degree relatives; any first-degree relative with a history of breast cancer diagnosed before the age of 50 years; two or more first- or second-degree relatives diagnosed with breast cancer at any age; patient or relative with diagnosis of bilateral breast cancer; and history of breast cancer in a male relative^◊.
Breast self-examination	All women should be counseled to perform monthly breast self-examination.
Mammography	Women treated with breast-conserving therapy should have their first posttreatment mammogram no earlier than six months after definitive radiation therapy. Subsequent mammograms should be obtained every 6 to 12 months for surveillance of abnormalities. Mammography should be performed yearly if stability of mammographic findings is achieved after completion of locoregional therapy.
Pelvic examination	Regular gynecologic follow-up is recommended for all women. Patients who receive tamoxifen therapy are at increased risk for developing endometrial cancer and should be advised to report any vaginal bleeding to their physicians. Longer follow-up intervals may be appropriate for women who have had a total hysterectomy and oophorectomy.
Coordination of care	The risk of breast cancer recurrence continues through 15 years after primary treatment and beyond. Continuity of care for patients with breast cancer is recommended and should be performed by a physician experienced in the surveillance of patients with cancer and in breast examination, including the examination of irradiated breasts. Follow-up by a PCP seems to lead to the same health outcomes as specialist follow-up with good patient satisfaction. If a patient with early-stage breast cancer (tumor <5 cm and <4 positive nodes) desires follow-up exclusively by a PCP, care may be transferred to the PCP approximately one year after diagnosis. If care is transferred to a PCP, both the PCP and the patient should be informed of the appropriate follow-up and management strategy. Re-referral for further oncology assessment may be considered, as needed, especially for patients who are receiving adjuvant endocrine therapy.
Not recommended
Routine blood tests	CBC testing is not recommended for routine breast cancer surveillance. Automated chemistry studies are not recommended for routine breast cancer surveillance.
Imaging studies	Chest x-rays are not recommended for routine breast cancer surveillance. Bone scans are not recommended for routine breast cancer surveillance. Ultrasound of the liver is not recommended for routine breast cancer surveillance. CT scanning is not recommended for routine breast cancer surveillance. FDG-PET scanning is not recommended for routine breast cancer surveillance. Breast MRI is not recommended for routine breast cancer surveillance.
Breast cancer tumor marker testing	The use of CA 15-3 or CA 27.29 is not recommended for routine surveillance of patients with breast cancer after primary therapy. CEA testing is not recommended for routine surveillance of patients with breast cancer after primary therapy.

CBC: complete blood count; CEA: carcinoembryonic antigen; FDG-PET: [¹⁸F] fluorodeoxyglucose-positron emission tomography; MRI: magnetic resonance imaging; PCP: primary care physician.
* All recommendations remain the same as those published in 2006 [Khatcheressian JL, Wolff AC, Smith TJ, et al. American Society of Clinical Oncology 2006 update of the breast cancer follow-up and management guidelines in the adjuvant setting. J Clin Oncol 2006; 24:5091]. The Panel concluded that there was no new evidence that warranted changing any of the recommendations. The 2006 guideline provides a detailed discussion and rationale for the recommendations.
¶ Although the evidence is lacking, it seems likely that history as well as physical and breast exams may also be conducted by experienced non-physician providers (eg, nurse practitioners, physician assistants) under the supervision of an experienced physician.
Δ UpToDate also offers free patient information content: www.uptodate.com/patients.
◊ Expert consensus-based recommendations are available with criteria specific to patients with cancer (eg, from the National Comprehensive Cancer Network [www.nccn.org]). These recommendations include similar criteria as those from the US Preventive Services Task Force as well as other criteria such as diagnosis of triple negative breast cancer, or a combination of breast cancer and other specific cancers.

Khatcheressian JL, Hurley P, Bantug E, et al. Breast Cancer Follow-Up and Management After Primary Treatment: American Society of Clinical Oncology Clinical Practice Guideline Update. J Clin Oncol 2013; 31:961. Reprinted with permission. Copyright © 2012 American Society of Clinical Oncology. All rights reserved.

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Summary of 2012 ASCO guideline recommendations for surveillance after breast cancer treatment